Surgery Marrow Pg 507-516 (Faciomaxillary Surgery)
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Questions and Answers

What is the primary function of sentinel lymph node biopsy (SLNB)?

  • To perform a full lymph node dissection
  • To assess the size of lymph nodes
  • To identify occult metastases and unexpected contralateral drainage (correct)
  • To determine the type of cancer present

    • The posterior triangle of the neck is bounded by the sternocleidomastoid, trapezius, and the midline.

    False

    Name the levels of lymph nodes present in the posterior triangle of the neck.

    Level V (V_a and V_b)

    The first draining nodes in thyroid cancer are located in the ______ region.

    <p>neck</p> Signup and view all the answers

    Match the following types of cancer with their related lymphatic drainage implication:

    <p>Carcinoma of the tip of the tongue = Contralateral lymph node drainage Lip cancer crossing midline = Contralateral lymph node drainage Soft palate carcinoma = Contralateral lymph node drainage T1, T2 tumors = Prophylactic lymph node dissection increases survival</p> Signup and view all the answers

    What is a common characteristic of both leukoplakia and candidiasis?

    <p>Presence of white patches</p> Signup and view all the answers

    Leukoplakia can be rubbed off easily.

    <p>False</p> Signup and view all the answers

    What type of leukoplakia is characterized by a reddish border?

    <p>Speckled leukoplakia</p> Signup and view all the answers

    Erythroplakia has an increased risk of cancer ranging from _____ to _____ times.

    <p>6, 9</p> Signup and view all the answers

    Match the following types of leukoplakia with their characteristics:

    <p>Proliferative Verrucous = High rate of cancerous conversion Speckled = Surrounded by a reddish border Erythroplakia = Reddish patch, high cancer risk Leukoplakia = Cannot be rubbed off</p> Signup and view all the answers

    Which procedure involves the removal of all tissue down to the fascia followed by split-thickness skin grafting?

    <p>Charles Procedure</p> Signup and view all the answers

    Skin necrosis is a complication associated with Thompson's Reduction.

    <p>False</p> Signup and view all the answers

    What is the primary complication associated with the Charles Procedure?

    <p>Worst cosmetic outcome</p> Signup and view all the answers

    The _____ procedure consists of a flap being raised, clearing out subcutaneous tissue, and then burying skin.

    <p>Thompson's Reduction</p> Signup and view all the answers

    Match the following surgical procedures with their descriptions:

    <p>Homans Procedure = Skin wedge resection and necrosis risk Thompson's Reduction = Flap raised and pilonidal sinus risk Charles Procedure = All tissue till fascia removed and STSG Microsurgery = Advanced reconstructive technique</p> Signup and view all the answers

    What does the term 'synchronous' refer to in the context of cancer?

    <p>Cancers that develop within 6 months of the primary cancer</p> Signup and view all the answers

    Metachronous cancers develop within 6 months of the primary cancer.

    <p>False</p> Signup and view all the answers

    What type of biopsy is used to confirm oral cancers?

    <p>Incisional biopsy</p> Signup and view all the answers

    The risk factors for field cancerization include involvement of the entire __________.

    <p>mucosa</p> Signup and view all the answers

    Match the following terms with their definitions:

    <p>Incisional biopsy = A biopsy performed to confirm the presence of cancer Synchronous cancer = Develops within 6 months of primary cancer Metachronous cancer = Develops after 6 months of primary cancer Field cancerization = Involves the entire mucosa leading to multiple cancers</p> Signup and view all the answers

    Which surgical approach is most commonly used for lip cancer?

    <p>Lip Split Approach</p> Signup and view all the answers

    The Visor Approach involves resection of the mandible and floor of the mouth.

    <p>True</p> Signup and view all the answers

    What is the primary indication for the Weber Ferguson Approach?

    <p>Maxillectomy</p> Signup and view all the answers

    In cases where the area of involvement is greater than two-thirds, the surgical approach is indicated for __________.

    <p>lip cancer</p> Signup and view all the answers

    Match each surgical approach with its description:

    <p>Johanson's Step Ladder Resection = A specific mid-lip surgical approach Flap Reconstruction = Reconstruction using adjacent tissue Visor Approach = Resection of mandible and floor of mouth Weber Ferguson Approach = Procedure used for maxillectomy</p> Signup and view all the answers

    What is the primary cause of elephantiasis?

    <p>Wuchereria bancrofti filariasis</p> Signup and view all the answers

    Lymphangioma can present with chronic skin changes in lymphedema.

    <p>True</p> Signup and view all the answers

    What is the treatment for elephantiasis?

    <p>Diethylcarbamazine (DEC)</p> Signup and view all the answers

    In phase 1 of conservative management for lymphedema, one method used is __________.

    <p>Manual Lymphatic Drainage (MLD)</p> Signup and view all the answers

    Match the types of lymphangioma with their description:

    <p>Circumscriptum = Nodules less than 5 cm Diffusum = Nodules greater than 5 cm Ab igne = Reticular arrangement of nodules</p> Signup and view all the answers

    Which of the following structures is NOT preserved in a Radical Neck Dissection (RND)?

    <p>Lymph nodes (levels I-V)</p> Signup and view all the answers

    Modified Radical Neck Dissection (MRND) preserves all extra lymphatic structures.

    <p>False</p> Signup and view all the answers

    What is the main characteristic of Functional Neck Dissection?

    <p>All extra lymphatic structures are preserved.</p> Signup and view all the answers

    In Selective Neck Dissection (SOHND), lymph nodes from levels I to _____ are removed.

    <p>III</p> Signup and view all the answers

    Match the types of neck dissection with their characteristics:

    <p>Radical Neck Dissection = Removes lymph nodes (levels I-V) and extra structures Modified Radical Neck Dissection = Removes lymph nodes (levels I-V) but preserves one extra structure Functional Neck Dissection = Preserves all extra lymphatic structures Selective Neck Dissection = Removes lymph nodes from levels I-III</p> Signup and view all the answers

    Which oral cancer is most commonly associated with keratin pearls?

    <p>Well differentiated squamous cell carcinoma</p> Signup and view all the answers

    Chronic hyperplastic candidiasis is considered a low risk lesion for oral cancer.

    <p>False</p> Signup and view all the answers

    What is the most common gene mutation found in oral cancers?

    <p>p53</p> Signup and view all the answers

    The most common site of oral cancer in India is the __________.

    <p>buccal mucosa/gingivo buccal sulcus</p> Signup and view all the answers

    Match the following types of oral lesions with their risk classification:

    <p>Erythroplakia = High risk Oral lichen planus = Low risk Oral submucous fibrosis = Medium risk Proliferative verrucous leukoplakia = High risk</p> Signup and view all the answers

    Which of the following factors is NOT associated with an increased risk for malignant change in pre-existing dysplastic lesions?

    <p>Smoker</p> Signup and view all the answers

    Oral submucous fibrosis is primarily caused by a hypersensitivity reaction to alcohol consumption.

    <p>False</p> Signup and view all the answers

    What clinical presentation is characterized by spoon-shaped nails in patients with Plummer-Vinson syndrome?

    <p>Koilonychia</p> Signup and view all the answers

    The management for Plummer-Vinson syndrome includes correction of _____ deficiency.

    <p>iron</p> Signup and view all the answers

    Match the following terms with their descriptions related to oral cancers:

    <p>Oral submucous fibrosis = Fibrosis leading to inadequate mouth opening Plummer-Vinson syndrome = Iron deficiency anemia with dysphagia Koilonychia = Spoon-shaped nails Angular cheilitis = Cracked corners of the mouth</p> Signup and view all the answers

    What T classification indicates a tumor size greater than 4 cm or depth of invasion greater than 10 mm?

    <p>T₃</p> Signup and view all the answers

    N₃b classification indicates involvement of multiple contralateral lymph nodes that are less than 6 cm.

    <p>False</p> Signup and view all the answers

    What is the definition of a wide local excision (WLE) in the context of surgical management of oral cancers?

    <p>A surgical procedure that removes a tumor with a margin of 0.5 cm around it to achieve microscopic freedom from disease.</p> Signup and view all the answers

    The ______ classification identifies tumors that involve adjacent structures and can be either resectable or not.

    <p>T₄</p> Signup and view all the answers

    Match the following nodal classifications with their definitions:

    <p>N₁ = Single ipsilateral lymph node ≤3 cm N₂a = Single ipsilateral lymph node &gt;3-6 cm N₂b = Multiple ipsilateral lymph nodes ≤6 cm N₃a = Single lymph node &gt;6 cm or extranodal extension</p> Signup and view all the answers

    Study Notes

    Prognosis

    • Penile Carcinoma: Verrucous variant, also known as Buschke-Lowenstein tumor, is slow-growing and has a better prognosis than other types.

    Leukoplakia vs Candidiasis

    • Common Feature: White patches on the tongue.
    • Leukoplakia:
      • Not characterized as any other condition.
      • Cannot be rubbed off.
      • Increased risk of cancer (3-5 times higher).
      • Management: Eliminate risk factors, use antioxidants, consider excision, CO2 laser, or cautery.
    • Candidiasis: Further information is not provided.

    Types of Leukoplakia

    • Proliferative Verrucous Leukoplakia:
      • Multifocal.
      • Usually has no typical risk factors.
      • High rate of cancerous conversion.
      • Management: Excision at the earliest stage.
    • Speckled Leukoplakia:
      • Leukoplakia surrounded by a reddish border.
      • Management: Excision.
    • Erythroplakia:
      • Reddish patch, not characterized by other conditions.
      • Cannot be rubbed off.
      • Increased risk of cancer (6-9 times higher).
      • Most aggressive type: Speckled erythroplakia.
      • Management: Eliminate risk factors, excision.

    Reconstructive Surgery

    • Procedures:
      • Lymphovenous anastomosis
      • Neubulowitz Sx
      • Microsurgery

    Resective Surgery

    • Indication: Advanced cases unresponsive to medical management.

    Homans Procedure (Surgical Management)

    • Steps:
      • Skin wedge resection.
      • Skin and subcutaneous tissue removal.
    • Complication: Skin necrosis.

    Thompson's Reduction (Surgical Management)

    • Steps:
      • Flap raised.
      • Subcutaneous tissue cleared.
      • Skin buried and closed.
    • Complication: Pilonidal sinus

    Charles Procedure (Surgical Management)

    • Steps:
      • All tissue till fascia removed.
      • Split-thickness skin grafting.
    • Complication: Worst cosmetic outcome.

    Lymph Nodes of the Neck

    • Levels:
      • IA: Submental
      • IB: Submandibular
      • II: Upper deep cervical
        • IIa: Anterior
        • IIb: Posterior
      • III: Middle deep cervical
      • IV: Lower deep cervical
      • V: Posterior triangle
        • Va: Superior
        • Vb: Inferior
      • VI: Central compartment nodes/pre & paratracheal nodes/Delphian lymph
      • VII: Mediastinal
    • Anterior Triangle of Neck:
      • Boundaries: Midline, Sternocleidomastoid, Angle of mandible.
    • Posterior Triangle:
      • Boundaries: Sternocleidomastoid, Trapezius, Angle of mandible.
    • Largest group of nodes: Boundaries: Sternocleidomastoid, Angle of mandible, Trapezius
    • Important Points:
      • T1, T2 tumors: Prophylactic lymph node dissection increases survival.
      • Sentinel lymph node biopsy (SLNB):
        • Shows occult mets and unexpected contralateral drainage.
      • Prophylactic elective neck dissection:
        • Selective neck dissection: Supraomohyoid dissection.
      • Carcinoma with contralateral lymph node drainage:
        • Angle of mouth
        • Carcinoma tip of tongue
        • Lip cancer crossing midline
        • Soft palate carcinoma
      • First draining nodes in thyroid cancer and laryngeal cancer: Lymph nodes in the neck.

    Field Cancerization

    • Oral cavity, Bladder, Colorectal region: (4% synchronous cancer)
    • Risk factors: Involves entire mucosa → multiple cancers.
    • Synchronous: Cancer develops within 6 months of the primary cancer.
    • Metachronous: Cancer develops after 6 months of the primary cancer.

    Clinical Relevance of Field Cancerization

    • Close observation and follow up.
    • Screening for other cancers.

    Work up of Oral Cancers

    • Confirmatory:
      • Incisional biopsy: edge/wedge biopsy (Center of the lesion: Necrotic)
        • Antibiotics are given in case of infection/inflammatory cells followed by a repeat biopsy.
    • Staging (IO): CECT of PNS, neck, & thorax
    • Tumor thickness and depth of invasion:
      • A diagram shows a vertical line representing the skin, a second line representing the tumor thickness, and a third line representing the depth of tumor invasion (DOI).

    Management of Lip Cancer (Surgical approaches)

    • Area of Involvement:
      • 1/3rd - 2/3rd: Middle portion of the lip.
      • >2/3rd: Larger portion of the lip, greater than two-thirds.
    • Approaches:
      • Johanson's Step Ladder Resection:
      • Flap Reconstruction:
      • Visor Approach: Resection of mandible and floor of mouth, lifting up the area for better access.
      • Weber Ferguson Approach: Indicated for maxillectomy.
      • Lip Split Approach: Most common approach, a mid-lip approach. Resection of mandible and buccal mucosa in some cases.

    Elephantiasis

    • Etiology: Wuchereria bancrofti filariasis.
    • Mechanism: Lymphatic system destroyed irreversibly. Microfilariae enter the peripheral blood during the night.
    • Treatment: Diethylcarbamazine (DEC)

    Lymphangioma

    • Symptom: Chronic skin changes in lymphedema.
    • Pathology: Lymphatic channels thrombose and fibrose, forming nodules.
    • Types:
      • Circumscriptum: Nodules less than 5 cm.
      • Diffusum: Nodules greater than 5 cm.
      • Ab igne: Reticular arrangement of nodules.

    Management of Lymphedema

    • Conservative Management:
      • Pain Relief
      • Skin Care: Dry skin is prone to infection.
      • Control Swelling:
        • Phase 1 (Short, Intensive): Manual Lymphatic Drainage (MLD), Multi-layer Lymphedema Bandaging (MLLB), Arterial/Venous disease (ABPI) is ruled out first.
        • Phase 2 (Maintenance): Self-care regimen
      • Exercises: Slow rhythmic isotonic movements. Avoid isometric exercises.
      • Other Interventions: Massages, Pneumatic Stockings, Limb Elevation.

    Neck Dissection Procedures

    • Radical Neck Dissection (RND):
      • Structures removed: Lymph nodes (levels I-V), extra lymphatic Structures (spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle). Tail of the parotid gland and submandibular gland are also removed.
    • Modified Radical Neck Dissection (MRND):
      • Structures removed: Lymph nodes (levels I-V), tail of parotid gland, and submandibular gland.
      • Structures preserved: At least 1 extra lymphatic structure.
    • Functional Neck Dissection:
      • Preserved Structures: All 3 extra lymphatic structures are preserved.
    • Selective Neck Dissection (SOHND):
      • Structures removed: Level I-III (above the omohyoid muscle)
    • Incision Types: Crile's, Martin's, Hockey stick, MacFee.

    Oral Cancers

    • Most common: Squamous cell carcinoma
      • Keratin pearls: Eosinophilic
    • Tumors:
      • Well Differentiated: Increased number of keratin pearls. p53 is the most common gene mutation in oral cancers. Most common site of oral cancer.
      • Poorly Differentiated: Decreased number of keratin pearls.
    • Risk Factors:
      • In India: Buccal mucosa/gingivo buccal sulcus most common
      • Worldwide: Lateral border of tongue most common.
      • Smoking
      • Alcohol
      • Betel quid
      • Immunosuppression
      • Sharp, ill-fitting dentures
      • Chronic infection
        • Hyperplastic candidiasis
        • Epstein-Barr Virus (EBV) - Nasopharyngeal carcinoma
        • Human Papillomavirus (HPV) - Oral squamous cell carcinoma (SCC) (5%) -> Oropharyngeal SCC (50-70%): Better prognosis.

    Pre-Malignant Conditions

    • High risk lesions:
      • Erythroplakia
      • Proliferative verrucous leukoplakia
      • Chronic hyperplastic candidiasis
    • Medium risk lesions:
      • Oral submucous fibrosis
      • Syphilitic glossitis
    • Low risk lesions:
      • Oral lichen planus
      • Diseases Limited Erythema (DLE)
    • Verrucous carcinoma/Ackerman tumor:
      • Variant of squamous cell carcinoma
      • Features:
        • HPV +ve
        • Outward growth
        • Slow growing

    Factors Associated with Increased Risk for Malignant Change in Pre-Existing Lesions

    • Females
    • Size > 200 mm2
    • Non-Homogeneous lesions
    • Non-smoker
    • Presence of multiple lesions
    • Location: Lateral border of tongue

    Oral Submucous Fibrosis

    • Cause: Hypersensitivity reaction to betel nut → Fibrosis.
    • Effects: Inadequate mouth opening → Poor hygiene → Increased risk of cancer
    • Clinical Examination: White bands in the mouth.

    Management of Oral Submucous Fibrosis

    • Stop: Betel quid consumption and smoking.
    • Antioxidants:
    • Intralesional triamcinolone:
    • Excision: Avoided due to healing by increased fibrosis.

    Plummer-Vinson Syndrome (AKA Patterson-Kelly Brown Syndrome, Sideropenic Dysphagia)

    • Common: Perimenopausal women
    • Clinical Presentation:
      • Iron deficiency anemia
      • Koilonychia (spoon-shaped nails)
      • Angular cheilitis/stomatitis
      • Intermittent dysphagia due to post-cricoid webs

    Management of Plummer-Vinson Syndrome

    • Correction of iron deficiency:
    • CO excision of webs:

    TNM Staging (8th AJCC Classification)

    • Tumor Staging:
      • Tx: Cannot be assessed
      • T₁: Size ≤4 cm, DOI ≤5 mm
      • T₂:
        • Size ≤4 cm, DOI 5-10 mm or
        • Size 2-4 cm, DOI ≤10 mm
      • T₃: Size >4 cm or DOI >10 mm
      • T₄: Involvement of adjacent structures
        • T₄a: Resectable
        • T₄b: Not resectable
    • Nodal Status:
      • Nx: Cannot be assessed
      • No: No lymph nodes involved
      • N₁: Single ipsilateral LN ≤3 cm
      • N₂a: Single ipsilateral LN >3-6 cm
      • N₂b: Multiple ipsilateral LN ≤6 cm
      • N₂c: Bilateral/contralateral LN ≤6 cm
      • N₃a: Single >6 cm or extranodal extension
      • N₃b: Clinical or radiographic extranodal extension - matted nodes - Attached to skin
    • Metastasis Status:
      • mx: Cannot be assessed
      • mo: No metastasis
      • m₁: Distant metastasis
      • m/c site of metastasis: Lung

    Management of Oral Cancers

    • SURGICAL MANAGEMENT
      • Wide local excision (WLE):
        • Ro resection: microscopic freedom from disease
        • Margin: 0.5 cm
      • Mandibular resection:
        • Indication: Involvement of mandible
      • Neck dissection:
        • Indication: Lymph node involvement
      • Reconstruction: Flaps
    • 1+2+3: Commando operation

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    Description

    This quiz covers the prognosis of penile carcinoma and the distinguishing features between leukoplakia and candidiasis. It also delves into the types of leukoplakia, their management options, and risks associated with each condition. Test your knowledge on these important oral health topics.

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